Introduction

Complementary and integrative health (CIH) consists of products and practices that are not currently part of mainstream, conventional medical practice.

CIH emphasizes patient empowerment, self-activation, preventive self-care, and wellness, often in conjunction with traditional medical treatment or in other alternative treatment settings. These approaches may be considered complementary (i.e., used in place of or used along with standard medical care). Integrative medicine refers to care that blends both mainstream and alternative practices.

The boundaries between CIH and conventional medicine are not absolute, although most CIH approaches fall into one of two subgroups: natural products (e.g., herbs, vitamins and minerals, and probiotics) and mind and body practices (e.g., yoga, meditation, massage therapy, acupuncture, and relaxation techniques).

In the United States, CIH approaches have gained popularity in recent years, and as a result, more research is focusing how CIH may improve various patient outcomes. According to the National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health, more than 30 percent of American adults and about 12 percent of children use health care approaches developed outside of mainstream conventional medicine.

New, Ongoing, and Published Research

In VA, complementary and integrative health (CIH) approaches are most commonly used to improve Veterans’ mental health, manage pain, and promote general wellness. More specifically, these approaches are often used to treat posttraumatic stress disorder (PTSD), depression, back pain, headache, arthritis, fibromyalgia (long-term pain throughout the body), and substance abuse.

One of the greatest challenges in CIH is critically examining the effectiveness of approaches that have not been rigorously tested through formal research. VA researchers remain committed to addressing these scientific gaps. They are conducting studies to determine which approaches are truly safe and effective, and for which conditions and populations they work best.

➤Natural products

Cinnamon may be good medicine for the brain—A research team at the Jesse Brown VA Medical Center in Chicago and Rush University found that, in mice, the spice cinnamon turns poor learners into good ones. They are hoping the same holds true for humans. In a study published in 2016, the team found that poor-learning mice took about 150 seconds to find the correct hole in a maze test. After a month of being fed cinnamon, they were finding the right hole within 60 seconds. The team hypothesizes that cinnamon acts as a slow-release form of sodium benzoate, a chemical produced as cinnamon is broken down in the body. Sodium benzoate can enter the brain and stimulate the hippocampus, the researchers believe.

Probiotics and Gulf War illness—Probiotics, such as the healthy bacteria found in yogurt, are living microorganisms that provide health benefits when consumed in the diet. VA researchers at the William S. Middleton Memorial VA Medical Center in Madison, Wisconsin, believe that probiotics may help ease the symptoms of Veterans with Gulf War illness (GWI).

The team is conducting a pilot study to learn if Veterans with GWI have problems with bacteria in their gastrointestinal tracts. Previous research has shown that a lack of bacterial diversity in the gut can lead to illnesses such as irritable bowel syndrome, diarrhea, constipation, abdominal bloating, and bowel urgency—some of the same symptoms many Veterans with GWI display.

By learning the differences in bacterial diversity between Veterans with GWI and those who do not have the illness, the team hopes to be able to construct a second trial that will identify probiotics that may ease GWI symptoms in a low-cost, well-tolerated, non-antibiotic treatment strategy. The initial trial is scheduled to be completed in 2020.

Fecal transplant treatment for infections and encephalopathy—In 2015, researchers with VA and the University of Minnesota systematically reviewed the scientific literature evaluating a procedure that dates back thousands of years. The procedure, called fecal transplantation, involves removing stool containing healthy bacteria from a donor and inserting it into a sick patient.

The investigators' review looked at the results of studies involving data for more than 500 patients with C. difficile infections, and learned that fecal transplantation proved successful in treating 85 percent of patients with recurring infections. The researchers concluded that such transplantation is a safe and effective way to treat recurrent infections.

In 2017, researchers from the Hunter Holmes McGuire VA Medical Center and the VCU School of Medicine successfully demonstrated that transferring stool from a healthy donor to cirrhosis patients with hepatic encephalopathy, a brain disorder that is a common complication of the liver disease, can improve brain functioning, reduce confusion, and reduce hospitalizations. The small study demonstrated that even in very sick patients with liver disease, fecal transplants can be safe and may improve brain functioning.

Curcumin for better mood function and cancer treatment—Curcumin is a key compound in the spice turmeric. In 2018, a study on rats undertaken by Olin E. Teague Veterans' Medical Center and Texas A&M University researchers found that curcumin may lead to better cognition and mood for those with GWI. In the study, rats with simulated GWI symptoms were treated with either curcumin or a placebo for 30 days. Besides better cognitive and mood function, those in the curcumin group had better growth and development of nerve tissues and less inflammation than the placebo group.

Curcumin is also being explored for its anti-cancer activity. A lab team at the Atlanta VA Medical Center and Georgia State University, working with collaborators in China, reported in 2015 on a combination chemotherapy drug containing curcumin and campothecin, a compound derived from the bark and stems of the "happy tree," a tree native to China. The team delivered the synergistic combination to colon cancer cells via a nanoparticle, which they say could prove to be viable way to target cancer cells without damage to other tissues.

CIH research into fish oil—Researchers at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, are conducting a study to determine whether fish oil favorably alters early brain changes associated with Alzheimer's disease by improving blood flow to the brain in Veterans with a family history for Alzheimer's. In the study, volunteers will take an 18-month regimen of eicosapentaenoic acid, an omega-3 fatty acid found in cold water fish including mackerel, herring, tuna, halibut, salmon, and cod liver. They will also undergo a series of brain imaging scans, lumbar punctures to retrieve cerebrospinal fluid, and memory and problem-solving tests. The study will end in 2021.

Researchers at the VA Iowa City Health Care System published a study in 2017 that found menhaden (fish) oil can improve and sometimes even reverse nerve damage in the eyes of diabetic rats. The effects were even more profound when fish oil was combined with α-lipoic acid, an antioxidant found in the body, and enalapril, a blood pressure medicine. The authors believe the approach may be effective for treating other vascular and neural complications of type 2 diabetes as well.

Ginger nanoparticles might be good for the gut—Ginger nanoparticles may soothe inflammatory bowel disease, according to a 2016 study by researchers with VA and the Institute for Biomedical Sciences at Georgia State University. They have developed nanoparticles derived from edible ginger that they believe may be good medicine for Crohn's disease and ulcerative colitis, the two main forms of inflammatory bowel disease. The particles may also help fight cancer linked to colitis, according to experiments in mice.

Vitamin E supplements to treat Alzheimer's—In the Jan. 1, 2014, issue of the Journal of the American Medical Association, a VA research team reported that taking supplemental vitamin E significantly delayed the decline of cognitive functioning in patients with mild to moderate Alzheimer's disease. The five-year study showed that the vitamin added, on average, six months of better cognitive functioning for patients with this progressive disease.

➤Mindfulness and meditation

Breathing meditation—Researchers at the VA Palo Alto Health Care System are enrolling Veterans with PTSD for a study comparing cognitive processing therapy with a breathing mediation technique called Sudarshan Kriya yoga. This form of yoga offers practical breath-based tools that, according to the study website, "decrease the stress, anxiety, and sleep problems that many returning Veterans experience." The study is expected to be completed in 2019.

Stress management and diabetes—People with diabetes must manage their illness every day to prevent potentially life-threatening and disabling complications such as kidney failure, acute coronary syndrome, and stroke. Many diabetes patients suffer from diabetes-related distress, a condition that makes it difficult to sustain healthy self-management behaviors. This is particularly problematic for Veterans with depression and PTSD.

A team of VA researchers at the VA Pittsburgh Healthcare System has developed a stress management program called Mind-STRIDE, which includes mindfulness training and home practice and can easily be integrated into diabetes self-management education programs. The team believes the information the program provides on managing stress will help diabetes patients both physically and psychologically.

The researchers are testing the program on 126 Veterans. Half of these Veterans will receive routine diabetes education alone, while the other half will receive the same education plus Mind-STRIDE. The team will compare the ability of participants in each group to control their illness, and will also compare participants' psychological outlooks. The study is estimated to be completed in 2019.

Mantram meditation—A 2016 study looked at the mantram form of meditation, a simple technique in which practitioners silently repeat a word or phrase that holds personal meaning for them. The study, involving 273 Veterans at six sites, was led by VA and University of California, San Diego, researchers. It evaluated the effectiveness of mantram repetition on depression, anxiety, and somatization (when psychological distress is expressed through physical symptoms).

The team also looked at two different ways facilitators are trained to teach mantram meditation. They found that with either approach, Veterans using the technique showed significant improvements in all outcomes, and that Veterans were highly satisfied with the experience.

A study published in 2017 by the same research team found that a mantram repetition program can help manage insomnia in patients with PTSD. Patients who participated in the program for eight weeks had significant improvement in insomnia symptoms and moderate improvement in PTSD symptoms. The team believes mantram meditation can be useful in addressing both insomnia and PTSD symptoms.

Mindfulness meditation—In 2015, a study found that mindfulness meditation was more successful than standard group therapy in treating PTSD. In the study, researchers with the Minneapolis VA Health Care System gave 58 Veterans nine sessions of mindfulness-based stress reduction therapy. This type of therapy focuses on teaching patients to attend to the present moment in a nonjudgmental, accepting manner.

A different group of 58 Veterans received nine weekly group therapy sessions focused on current life problems. Two months after the sessions were completed, nearly half (48.9 percent) of those in the meditation group reported clinically significant improvement in the severity of their PTSD symptoms, compared with 28 percent of those who received group therapy.

Meditation and cardiovascular risk—In 2017, the American Heart Association (AHA) issued a scientific statement that meditation can reduce the risk of cardiovascular disease. The AHA council, which included several VA researchers, reviewed more than 400 scientific articles on meditation and found that medication can have long-standing effects on the brain, which may lower cardiovascular disease risk.

According to the AHA, meditation may be able to help with cardiovascular risk factors such as stress, smoking, high blood pressure, and various metabolic functions. More research is needed, however, according to the authors.

Spirituality and PTSD—Researchers at the Durham VA Medical Center, the Charlie Norwood VA Medical Center in Augusta, Georgia, and Augusta University are currently conducting a survey to determine what role spirituality plays in the life of Veterans with PTSD, and whether they would be interested in having a spirituality-based therapy available. The team will conduct a randomized control trial to compare current psychotherapy approaches such as cognitive processing therapy and prolonged exposure with one that incorporates a spiritual element. The therapy will be voluntary and would incorporate the patient's own religion and religious texts.

➤Mind-body practices

Yoga treatment for PTSD—Military sexual trauma is the most common cause of PTSD in women Veterans. In a 2015 study, researchers established the feasibility of using yoga to treat PTSD and depression symptoms in women Veterans who experienced military sexual trauma. This study involved 42 female Veterans from the Atlanta VA Medical Center. The trauma-sensitive yoga treatment showed a trend toward reducing PTSD, depression, and chronic pain symptoms.

The researchers are now conducting a larger, four-year trial to test the effectiveness of this treatment. They are recruiting women Veterans seeking treatment for PTSD related to military sexual trauma who have chronic pain and trouble sleeping. The study's estimated completion date is the end of 2019.

Yoga may help to alleviate symptoms of menopause—In 2017, Durham VA Medical Center researchers conducted a meta-analysis investigating the use of yoga among menopausal women. They found that yoga may reduce vasomotor symptoms, such as hot flashes, and psychological issues, such as anxiety and mood disturbances. However, because only one review and three randomized controlled trials were available on the subject, they cautioned that more research with larger numbers and control groups is needed before widespread recommendations can be made.

Yoga and depression—Led by researchers at the San Francisco VA Medical Center, a study of male Veterans found that hatha yoga, the branch of yoga that emphasizes physical exercises along with meditative and breathing exercises, may reduce symptoms of depression. In the study, 23 men participated in twice-weekly yoga classes for eight weeks. The Veterans enjoyed the classes, and participants with elevated depression scores before the yoga program began had a significant reduction in depression symptoms after it was completed.

Studies of tai chi—Tai chi is a series of slow, low impact movements that integrate the breath, mind, and physical activity to achieve greater awareness and a sense of well-being. In a study published in 2016, researchers from the VA Greater Los Angeles Health Care System, the University of California, Los Angeles, and the Rand Corporation created an evidence map that describes the volume and focus of the effects of tai chi on health.

The team's review of 107 different studies, two-thirds of which were published in the last five years, identified that tai chi could have a positive treatment effect on patient outcomes related to hypertension, fall prevention, cognitive performance, and pain. However, the team noted that firm conclusions could not be drawn because of methodological limitations in the original studies or because there were an insufficient number of existing research studies.

The VA Boston Healthcare System is currently conducting a randomized trial to test the effectiveness of tai chi in the context of Gulf War illness (GWI). The team is recruiting 120 Gulf War Veterans with GWI who will either practice the discipline regularly or participate in wellness education, a skills-based class focusing on exercise, surroundings, diet, sleep habits, relationships, spirituality, and relaxation. The research team expects that both groups will experience fewer symptoms as a result of participating in the study. The study will end in 2021.

How exercise affects the brain—Exercise can combat health conditions and diseases, including cardiovascular disease, stroke, and depression. Two researchers from the VA Palo Alto Health Care System and Stanford University are conducting a study to determine just what it is about exercise that is so beneficial to the brain—in the belief that pinpointing these mystery factors might help prevent common aging-related diseases such as Alzheimer's.

According to the researchers, during exercise muscles secrete molecules that are beneficial to the body and the brain. Within those molecules are hormones, growth factors, and small proteins—called cytokines—that are integral for cell signaling.

The study will be the first systematic attempt to tie these molecules to their specific effects on the brain and cognition. Researchers will take blood from an exercised animal and inject it into an unexercised animal, in hopes of seeing positive effects. They will then analyze the blood to see what factors are responsible for the changes. The study's estimated completion date is 2018.

Exercise and breast cancer—An exercise program improved cognitive functioning in patients recently diagnosed with breast cancer, according to a 2018 study by researchers with VA and the University of California, San Diego. Within two years after cancer surgery, patients scored better on a test of processing speed after a 12-week exercise program compared with those not in the exercise program. However, patients who had surgery more than two years previously did not show faster processing.

Warrior wellness program—Researchers at the Durham VA Health Care System in North Carolina are conducting a study to determine whether regular exercise can alleviate the symptoms of PTSD in older Veterans. Veterans participating in the study take part in a supervised 12-week exercise plan consisting of activities focused on strength, flexibility, balance, and endurance training. The extensive exercise regimen can be adapted to individual musculoskeletal ailments. Fifty-four Veterans, all at least 60 years of age, are participating in the study. Two-thirds are participating in the exercise plan; the rest are free to pursue existing VA health initiatives. The study is expected to be completed in 2019.

Exercise may help with symptoms of Parkinson's disease—A 2014 study by researchers with the Iowa City VA Health Care System and other sites found that 60 patients with Parkinson's disease who walked briskly for 45 minutes three times a week for six months showed improvements in their Parkinson's symptoms. The participants' motor function and mood improved by an average of 15 percent. Their tiredness was reduced by 11 percent, and their attention and response control improved by 14 percent.

➤Integrative health approaches in suicide prevention

Health-promoting behaviors may reduce suicidal thoughts in Veterans with PTSD—Research has shown that Veterans with PTSD are more likely to have suicidal thoughts than those without PTSD. However, a survey of more than 100 Iraq and Afghanistan Veterans with PTSD led by researchers with VA's VISN 17 Center of Excellence for Research on Returning War Veterans in Waco, Texas, published in 2016, found that those Veterans with PTSD who routinely engaged in activities to foster good nutrition, physical activity, stress management, spiritual growth, health responsibility, and interpersonal relationships have a less pronounced link to such thoughts.

The researchers believe that promoting these activities in Veterans with PTSD could help lower suicide risk among that group of Veterans.

Preventing suicide through mindfulness-based cognitive therapy—Suicide prevention is one of the priority areas for VA research, and there is a great need for evidence-based psychotherapies that specifically address suicidal behavior. However, research into new psychotherapies is limited. As such, the VA has invested in research to evaluate new and innovative potential therapies.

One of these new psychotherapies is mindfulness-based cognitive therapy for Suicide (MBCT-S). In 2013, the VA funded a research team from New Jersey to look at the impact of MBCT-S among military Veterans who visited outpatient VA treatment facilities. The study is determining if MBCT-S is more effective than usual treatment in reducing suicide events; reducing suicide attempts; and reducing the severity of suicide ideation, depression, and hopelessness. The study ends in 2018, with results forthcoming.

Spirituality and suicide prevention—A 2016 study by researchers with the VA Center of Excellence for Suicide Prevention in Canandaigua, New York, examined the relationship of spiritual life with a history of suicidal thoughts in Veterans diagnosed with PTSD. The team found that within a group of 477 Veterans with PTSD, those who did not participate regularly in spiritual practices, were angry at a higher power, or felt they had fallen short of religious expectations were more likely to have suicidal thoughts than those who had positive thoughts about religion and religious practices.

➤Complementary approaches to pain management

CIH use among Veterans with chronic pain—Many Veterans suffer from chronic musculoskeletal pain, and this type of pain is often difficult and costly to treat. VA researchers examined the medical records of more than half a million Veterans with musculoskeletal pain to determine how those who used CIH approaches (e.g., acupuncture, biofeedback, guided imagery, therapeutic massage, meditation, tai chi, yoga, hypnosis, and chiropractic care) to managing their pain differed from those who did not use these approaches.

Findings revealed that 27 percent of Veterans were using at least one of these CIH approaches. Furthermore, those that did use at least one approach reported slightly less pain and had slightly lower health care costs than those who did not use any of the CIH approaches. Researchers concluded that this study’s findings could be used to help the VA determine what cost-effective CIH approaches could be targeted for nondrug pain management.

Yoga helps chronic low back pain—Chronic low back pain affects many Veterans, but many current treatment options have limited effectiveness. In addition to chronic pain, people with this issue experience increased disability, psychological symptoms such as depression, and reduced quality of life.

In a study published in 2017, researchers from the VA San Diego Healthcare System examined the impact of yoga for improving function and decreasing pain. Of the 152 patients enrolled in the study, half attended 60-minute hatha yoga classes twice weekly for 12 weeks. The others continued their existing treatments and were asked not to do yoga for six months.

They found that those taking the yoga classes lessened the intensity of their pain more than the control group by the time the classes ended, and still had less pain six months after the study began. Opioid medication use for pain declined among all participants in the study. The team believes that its findings support wider implementation of yoga for Veterans.

Caregiver-assisted massage may reduce pain—In 2016, a team with VA's Evidence-based Synthesis Program (ESP), based at the VA Greater Los Angeles Healthcare System, published a report on the potential benefits of massage for neck and other types of pain, but concluded that larger, more rigorous studies were needed. In 2017, a research team from the Richard L. Roudebush VA Medical Center in Indianapolis and Indiana University began a study to see if neck pain can be alleviated by regular massages given by Veterans' caregivers.

The study is enrolling 468 Veterans with chronic neck pain. "Care allies," who are not trained massage therapists but will receive training in specific massage techniques related to neck pain, will provide 156 of them with massages. The others will be in one of two control arms: a group that gets massages from professional therapists and another that receives usual care.

The hope is that the care allies will provide multiple hour-long sessions to the Veterans for multiple weeks, which is the amount of massage therapy most beneficial to those with neck pain—a dosage that is difficult to obtain from professional therapists. The study is scheduled to be completed in 2021.

How electroacupuncture works—Electroacupuncture is a modern-day variation of the ancient Chinese art of acupuncture. Acupuncture is a system of complementary medicine that involves pricking the skin or tissues with needles at specific points on the body to alleviate pain and treat various physical, mental, and emotional conditions. In electroacupuncture, the needles carry a mild electrical current.

As described in a 2017 article, a team of 40 researchers in the United States and South Korea, including VA researchers from Indianapolis, provided a picture of how electroacupuncture eases pain and promotes tissue repair. They found that electroacupuncture triggers the release of mesenchymal stem cells into the blood stream. These are adult stem cells found mainly in the bone marrow, and are being studied widely for their healing potential.

The research team believes the cells may be responsible for a range of therapeutic effect, such as the release of proteins that quell inflammation, and of the body's own natural opioids.

Evidence lacking for benefits of medical marijuana—In 2017, researchers from the VA Portland Health Care System and Oregon Health and Science University systematically reviewed 75 scientific publications on the effects of medical marijuana for many types of chronic pain.

They found limited evidence that marijuana use might alleviate neuropathic pain in some patients, and that it might reduce spasticity associated with multiple sclerosis. Researchers concluded there was insufficient evidence on the benefits of marijuana for all other pain types.

Current federal law prohibits the use or dispensing of marijuana. As a federal agency, VA follows this prohibition and does not prescribe medical marijuana to any of its patients.

➤Health care provider wellness

Mantram improves nursing care—Mantram repetition program (MRP) is a mind-body-spiritual approach to stress management. In 2014, researchers from the Edwards Hines, Jr. VA Hospital were funded to evaluate how an internet-based MRP (I-MRP) could benefit VA registered nurses (RNs) delivering care to hospitalized Veterans. Participating RNs completed a six module I-MRP. Then the researchers followed up by asking the RNs and their patients a series of questions related to changes in the RNs’ behaviors.

Upon program completion, RNs reported higher levels of perceived mindfulness, spiritual well-being, and compassion satisfaction. The RNs’ patients reported high levels of nursing presence and were highly satisfied with their nursing care. Study authors concluded that I-MRP usage by RNs could facilitate nursing presence and the delivery of patient-centered nursing care.

Animal therapy and VA employee wellness—Animal therapy has been shown to benefit employee wellness in many ways, including by reducing stress, reducing absenteeism, and increasing productivity levels. Furthermore, animal therapy may also improve employee quality of work, morale, and job satisfaction.

People with tinnitus hear a persistent sound that can range from ringing or buzzing to a hissing or white noise hum, when there is no external sound source. The distraction can impair people's ability to sleep or concentrate, and is sometimes disabling.

The 64 participants enrolled in the study received either 2,000 pulses per session of TMS or a placebo for 10 consecutive workdays. Six months later, 56 percent of those receiving TMS positively responded to the treatment, compared with 22 percent of those in the placebo group.

The investigators asserted that before this procedure can be clinically implemented, larger studies should be conducted to refine treatment protocols.

TMS for persistent headaches—VA researchers are looking at the potential benefits of transcranial magnetic stimulation (TMS) for a variety of conditions involving the brain. In TMS, clinicians take an electromagnetic coil, charge it with electricity, and apply it to specific points on the skull. The result is a targeted magnetic field that can affect brain cells in a specific area.

TMS is FDA-approved for major depression that does not respond to other treatments, and for certain types of migraines. In 2015, researchers at the VA San Diego Healthcare Systemstudied 24 Veterans who had persistent daily headaches related to mild traumatic brain injury. Half of the participants received TMS three times within a week, and the other half did not receive the treatment.

After one week, about 58 percent of the TMS-treatment group showed at least a 50 percent reduction in headache intensity, versus only 17 percent of the control group. After four weeks, the TMS-treatment group continued to show greater improvement.

➤NIH-DOD-VA Pain Management Collaboratory

One of the exciting CIH initiatives being undertaken at VA involves participation in the NIH-DOD-VA Pain Management Collaboratory (PMC). Launched in 2017, PMC is investing $81 million over six years to fund a portfolio of research projects that will develop, implement, and test nondrug approaches for pain and related conditions in military personnel and Veterans. PMC’s goal is to develop the capacity to implement cost-effective, large-scale, pragmatic clinical research in military and Veteran health care delivery organizations.

To date, PMC funds 11 studies that are being conducted in health care settings serving military personnel, Veterans, and their families around the country. VA HSR&D sponsors one study which will evaluate the effectiveness of adding self-care practices (e.g., meditation/mindfulness, tai chi, and yoga) to practitioner-delivered CIH care for Veterans with chronic musculoskeletal pain. The study aims to improve pain, pain-related conditions, and opioid use